Cardiac arrest is responsible for 5% – 10% of all deaths among children age 5–19 years; therefore, strategies to prevent poor outcomes post cardiac arrest among children are critical within schools.
The purpose of this study was to systematically review the effectiveness of cardiopulmonary resuscitation (CPR) training on CPR knowledge and skills among adolescent school children.
This systematic review was conducted and reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. The complete bibliographic databases of PubMed, Cochrane Library, CINAHL and Web of Science were searched from January 2012 to August 2021. Included studies met all the eligibility criteria. The Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies (EPHPP) and Mixed Method Appraisal tool were used to appraise the quality of the included studies.
Fourteen studies were included in the review, and 5418 participants were found in the databases. The studies were mainly conducted during the last decade, which suggests that the public’s attention has been directed toward training schoolchildren in CPR. The most common interventions were taught in video simulation training courses. They also used subjective assessments to evaluate the participants’ knowledge and skills.
Findings from this systematic review reveal that CPR training within school settings effectively promoted a change in CPR knowledge and skills among adolescents. Hence, continuous training of CPR among schoolchildren should be encouraged by policymakers, school authorities, parents and teachers to optimise the prompt usage of the skills in any cardiac event. However, a high-quality randomised controlled trial would enhance the strength of evidence in this area.
Out-of-hospital cardiac arrest (OHCA) has remained a significant public health concern. Out-of-hospital cardiac arrest accounts for a substantial number of death worldwide (Pivač, Gradišek & Skela-Savič
The CPR intervention is essential in improving the chances of survival of cardiac arrest patients in and out of the hospital setting. Early initiation and good quality of CPR by bystanders and automated external defibrillator use are crucial for saving patients in cardiac arrest. However, the implementation rate for bystander CPR is reported to be low (Xu, Zhang & Chen
In OHCA, these critical linked interventions mostly rely on a layperson, who is often the first on the scene (Chocron et al.
Furthermore, early CPR training enhances the safety culture of schools and the role of the teachers to the pupils. For example, should one of the adolescent learners experience cardiac arrest on the soccer field while the teacher is absent, the pupil trained in CPR can save another pupil’s life by acting promptly according to the chain of survival links. This can result in long-term structural changes of accountability and confidence in performing in such emergency situations. Furthermore, the pupils trained in CPR can serve as CPR multipliers, as they may pass on the acquired CPR knowledge and skill to family members and friends.
As recommended by the American Heart Association (AHA), the drive for CPR training is a golden opportunity to improve school and community health (Nordheim
The aim of this study was to systematically review the effectiveness of CPR training in schools and its impact on CPR knowledge and skills among adolescents.
This systematic review was conducted and reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Moher et al.
Independent reviewers B.B. and N.E.Z. searched the databases of PubMed, CINAHL and Cochrane Library to identify studies that were published from January 2012 until August 2021. Medical Subject Headings (MeSH) and free text terms were used in the search to the find studies. For the Web of Science search, a combination of terms and truncation was used. Only human studies that were peer reviewed and published in English were considered. A manual search was also conducted from the references of the studies and other sources to complete the review. See full search strategies in
Characteristics of included studies.
Studies were eligible for inclusion if they examined the effects of CPR programs or basic life support (BLS) training (specifically, CPR programs), on CPR knowledge retention, skills, attitudes and perceptions of CPR usage in adolescents between the ages of 12–18 years (
All identified articles were exported into EndNote (Clarivate Plc, London, United Kingdom) to remove duplicates and then uploaded onto the Covidence online software (Veritas Health Innovation Ltd, Melbourne, Australia) for screening. The identified articles were initially screened based on titles and abstracts, based on two researchers’ eligibility criteria (B.B. and N.E.Z.). Then the same researchers screened the full-text copies of articles that scaled through the title and abstract screening after removing irrelevant articles. A third author (U.U.) resolved potential areas of disagreement on whether to include or exclude articles. Finally, the references of articles identified through database searches were examined to determine any further potentially relevant studies. See complete search strategies in
The Cochrane Collaboration recommended tool for quantitative studies, Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies (EPHPP), was used to appraise the quality of the included quantitative studies (EPHPP
Quality appraisal summary of the included studies.
Study | Selection bias | Study design | Confounders | Blinding | Data collection methods | Withdrawals and dropouts | Overall study quality |
---|---|---|---|---|---|---|---|
Barsom et al. ( |
1 | 1 | 1 | 3 | 1 | 1 | Moderate |
Cortegiani et al. ( |
1 | 1 | 1 | 3 | 1 | 1 | Moderate |
Fonseca Del Pozo et al. ( |
2 | 1 | 1 | 3 | 1 | 1 | Weak |
Haseneder et al. ( |
1 | 1 | 1 | 2 | 1 | 1 | Moderate |
Li et al. ( |
1 | 1 | 1 | 3 | 1 | 1 | Moderate |
Meissner et al. ( |
1 | 2 | 2 | 3 | 1 | 1 | Weak |
Nord et al. ( |
1 | 1 | 1 | 3 | 1 | 1 | Moderate |
Mathew et al. ( |
1 | 2 | 1 | 3 | 1 | 1 | Weak |
Onan et al. ( |
2 | 2 | 1 | 3 | 1 | 1 | Weak |
Paglino et al. ( |
1 | 1 | 1 | 3 | 1 | 1 | Moderate |
Suss-Havemann et al. ( |
1 | 1 | 1 | 1 | 1 | 1 | Strong |
Tsai et al. ( |
1 | 2 | 1 | 3 | 1 | 1 | Weak |
Wingen et al. ( |
1 | 1 | 1 | 3 | 1 | 1 | Weak |
Pivač et al. ( |
1 | 2 | 1 | 3 | 1 | 1 | Moderate |
This article followed all ethical standards for research without direct contact with human or animal subjects.
A total of 143 articles were retrieved from the databases. After the 41 duplicates were removed, 102 were screened for abstract and title, and 81 were excluded. Twenty-one of these were considered for full-text eligibility, and 12 were rejected because they did not meet the eligibility criteria. Fourteen studies (nine RCTs and five non-RCTs) were included in this systematic review. The majority of the studies were of moderate to weak quality.
Evidence of synthesis and characteristics of the included studies.
Authors (year) and country | Study design | Age range (years) | Number of participants | Intervention | Control | Outcomes measured | Findings | Conclusion |
---|---|---|---|---|---|---|---|---|
Barsom et al. ( |
RCT | 16 | 40 | Virtual reality (VR) | Standard training | A questionnaire concerning statementson useability, self-confidence, content and overall quality | The VR group had a significantly higher increase in correct answers in comparison with the standard group. | The use of VR training for CPR training appears to be an effective learning method for nonmedical students and may be of great value skilling high school students in becoming adequate CPR providers |
Cortegiani et al. ( |
RCT | 17–18 | 144 | Real-time feedback during chest compressions with the guidance of an instructor | Based on standard instructor-based feedback | The primary outcome of vthe study was the compression score calculated by Laerdal QCPR1 software 7 days from the training | Students in the QCPR group had a significantly higher compression score compared to the SF group. Students in QCPR group performed significantly higher percentage of fully released chest compressions and rate | Training for chest compressions based on real-time feedback software guided by an instructor is superior to instructor-based feedback training for chest compression skills |
Fonseca Del Pozo et al. ( |
RCT | 12–14 | 122 | CPR song and video | Standard | To assess the acquisition of theoretical knowledge, a CPR questionnaire was used | No significant difference between experimental and intervention group in terms of CPR knowledge 1 month post intervention. However, at 8 months there were significant differences between the groups | The study showed that incorporating the song component in the CPR teaching increased its effectiveness and the ability to remember the CPR algorithm |
Haseneder et al. ( |
RCT | 10–17 | 460 | BLS training conducted by emergency physicians | BLS training conducted by medical students | Subjective assessment of BLS knowledge and self-confidence | BLS knowledge increased from 5.86 to 9.24 and self-confidence increased from 8.70 to 11.29. After 9 months, knowledge retention was good but self-confidence significantly declined | BLS training led to short-term gains in knowledge and self-confidence. Although knowledge was retained at 9 months after the training session, self-confidence significantly decreased |
Li et al. ( |
RCT | 13–14 | 1093 | CPR, instructor-led | Nil | The primary outcome f the investigation was the correct rate of CPR knowledge-related items | After training, bystander CPR theory was significantly improved, and students reached an 85% – 100% performance rate in a simulated BLS scenario | Schoolchildren in China have a poor pretraining knowledge of bystander CPR. However, with training, there was a significant improvement in the basic theory and skills of CPR |
Meissner et al. ( |
Longitudinal prospective cohort study | 14–15 | 132 | CPR, instructor-led | Nil | BLS performance with a yes-or-no checklist in each practical assessment | Before the training, 29.5% of students performed chest compressions as compared to 99.2% post-training. At the 4-month follow-up, 99% of students still performed correct chest compressions. |
BLS training in high school seems highly effective considering the minimal amount of previous knowledge the students possessed |
Nord et al. ( |
RCT | 12–13 | 587 | CPR training with a practical test, including feedback (T), or CPR training with reflection and a practical test, including feedback | Basic CPR training only (O) | The primary endpoint was the total score for the modified Cardiff test at 6 months | At 6 months, the T and O groups scored 32 (3.9) and 30 (4.0) points, respectively ( |
A practical test including feedback directly after training improved the students’ acquisition of practical CPR skills. Reflection did not increase further CPR skills |
Mathew et al. ( |
Prospective interventional study | 12–16 | 810 | Basic CPR training and video demonstration | Nil | CPR knowledge assessment was done with a 10‑statement questionnaire covering 3 aspects: basic knowledge, theoretical aspects and algorithm of hands‑only CPR | 68% of middle school students, 79% of secondary school children and 82% of senior secondary school children performed correctly chest compressions in terms of rate, depth and duration | Theoretical training of CPR can be started at the middle school level, and practical training can be incorporated in the school curricula from secondary school |
Paglino et al. ( |
Interventional study | 14–19 | 318 | CPR video-based training | Nil | A theoretical questionnaire, made up of six questions on CPR and a practical test of 1 min of compression- only CPR on a Laerdal Resusci Anne Wireless Skill Reporter mannikin | Three months post intervention, 98% of the students knew when to perform CPR and 97% were competent in the BLS sequence. Post training after 6 months, 98% knew the theoretical skills of BLS, 96.5% knew when to perform, 95% were competent on the practical test with correct chest compression rate, depth and hand placement | Training schoolteachers to teach students in high schools using video-based training provides a good retention of both theoretical and practical skills after 3 and 6 months |
Onan et al. ( |
Quasi-experimental study | 12–17 | 83 | CPR, instructor-led | Standard self-training | BLS knowledge test using 15 multiple-choice questions and CPR performance | Instructor-led CPR increased the BLS knowledge significantly | Simplified BLS training increases BLS knowledge scores; thus, BLS training should be a mandatory component of the high school curriculum |
Pivač et al. ( |
Mixed methods study | 12.5–14.5 | 746 | Basic CPR training | Standard | Knowledge of CPR was measured using a structured questionnaire consisting of four sections with 27 nominal-level binary questions | Significant progress in CPR knowledge was noted after training implementation, with increase in the following variables: attitude in helping others ( |
Early CPR training is recommended in school as it will raise awareness of the responsibility to help others provide quality bystander CPR; thus, it should be mandatory in the school curricula |
Suss-Havemann et al. ( |
RCT | 12 | 307 | Basic CPR training with a skill-testing scenario | Standard | Practical skills were evaluated during a 3-min scenario testing using a nine-point standardised checklist | This study could not measure a higher self-efficacy for helping in cardiac arrest of the students participating in the intervention compared to the control group ( |
The study could not demonstrate that self-regulated learning supports higher self-efficacy for helping in cardiac arrest in students |
Tsai et al. ( |
Quasi-experimental pre-post study | 12–17 | 336 | 50-minute CPR and automated external defibrillator training | Standard | CPR knowledge was tested using a questionnaire with 10 items | Improved knowledge of emergency response, correct CPR at home and willingness to help | Early CPR training in schools significantly improves immediate knowledge of CPR in school children and empowers them to act |
Wingen et al. ( |
RCT | 14–18 | 424 | 90-minute basic CPR training | Standard | CPR knowledge was tested using a previous validated questionnaire | School children in the intervention group showed a significantly higher level of knowledge ( |
CPR training improves the level of knowledge and self-confidence in schoolchildren |
RCT, randomised controlled trial; CPR, cardiopulmonary resuscitation; QCPR, quality cardiopulmonary resuscitation; BLS, basic life support; SF, standard with feedback; RT, reflection with training; VR, virtual reality.
Only one study (Suss-Havemann et al.
This review showed that CPR training within school settings among adolescents effectively enhances adolescents’ knowledge, skills and confidence in providing CPR for peers and bystanders with OHCA. The only strong quality RCT in this systematic review demonstrated a lack of self-efficacy scores for helping students with OHCA. This could be because the authors measured self-efficacy in assisting students with cardiac arrest, not participants’ CPR knowledge post-training. Previous studies (Pivač et al.
Western countries have shown that children can learn these basic CPR skills and prevent sudden OHCA. However, findings from this review showed that no country in sub-Saharan Africa had carried out CPR intervention in school settings among adolescents.
Unfortunately, in sub-Saharan Africa, approximately 5 million deaths each year are attributable to conditions that could have been addressed by prehospital care, which is underdeveloped in most low- and middle-income countries, such as cardiac arrest (De Buck et al.
The studies revealed that the training intervention typically targeted adolescents from ages 14 to 18, mainly due to their physical structure and maturity to demonstrate the skill required and retain the theoretical component of the training. In the 14 studies included in this review, the duration of activity ranged from 50 min to 4 h, including the practical and didactic components. Research by the AHA supports effective CPR training intervention; the longer the duration, the more significant improvement is observed in knowledge and retention of information (Cave et al.
In this review, the most common interventions used in adolescents’ CPR training were instructor-led basic CPR training with video simulations of chest compression, basic CPR theoretical training with mannikins and video gaming to teach CPR to students (virtual reality). In addition, the AHA introduced the Blended Learning Program in 2015. This concept involves the use of video- and computer-based modules to deliver self-paced, online training in CPR. Unfortunately, while it has been widely used in the United States, it is not yet commonly utilised in Africa because of the coronavirus disease 2019 (COVID-19) pandemic. This review is still important and relevant, because the authors recognise that adolescents will become elders in the future if they are taught and can perform CPR in an emergency such as cardiac arrest; they may be able to save the lives of cardiac arrest victims and educate their younger siblings, increasing bystander rates.
This systematic review revealed that most adolescents had limited knowledge and skills on CPR, as observed in the pretest questionnaires distributed in all studies where participants had no previous experience of CPR. Furthermore, out of the 14 included studies, the adolescents demonstrated no bystander effect before training, a psychological phenomenon involving an unwillingness to assist a person with cardiac arrest. The main reason was limited knowledge and fear of causing further injuries to the cardiac arrest victim.
The studies’ predominant tool for outcome measure was questionnaires combined with technical skills assessed by the instructors after the CPR training interventions (Haseneder et al.
This systematic review revealed vast numbers of CPR school-based training interventions offered to adolescents, especially in Western countries. Tsai et al. (
The major limitation of this review was the lack of any study from the African continent that reported on school-based CPR training among the adolescents, which made it impossible to compare what training intervention strategy works best for resource-limited settings. The other limitation included not having much information that could realistically provide data of the adolescents providing CPR for a real-life scenario post-training.
Firstly, there should be an urgent and immediate need for CPR training among adolescents in Africa. Secondly, research should focus on the best implementation strategy that would be sustainable in a low-resource setting. Thirdly, high-quality RCTs would be needed to provide evidence-based intervention on the effectiveness of CPR training implemented within school settings to promote change in CPR knowledge, skills and behaviour among adolescents. Lastly, low- and middle-income countries should allocate resources and funds to purchase mannikins and other training materials that would help enhance CPR training among adolescents in schools.
The findings from this study showed that CPR training within school settings effectively promoted a change in CPR knowledge and skills among adolescents. Hence, continuous training of CPR among schoolchildren should be encouraged by policymakers, school authorities, parents and teachers to optimise the prompt usage of the skills in any cardiac event.
The authors would like to acknowledge the Faculty of Health Care Science dean in North-West University (NWU) for providing the authors funding for the CPR manikins to facilitate CPR training in North West province high schools among the adolescents. The community engagement inspired the writing of this systematic review. We would like to also thank the Quality in Nursing and Midwifery (NuMiQ) research focus area for funding the publication fees for this article.
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.
N.E.Z. was involved in the conceptualisation, methodology, analysis, writing of the original draft, software handling and editing and review of the manuscript. B.B. was also involved in the conceptualisation, methodology, analysis, writing of the original draft, software, validation and editing and review of the manuscript. M.M. was also involved in the software, validation and editing and review of the manuscript. U.U. was involved in the project administartion, methodology, supervision and editing and review of the manuscript.
Faculty of Health Care Science dean at North-West University (NWU) provided the authors funding for the CPR manikins and Quality in Nursing and Midwifery (NuMiQ) research focus area for funding the publication fees.
The data of this manuscript will be readily available on the North West University repository as soon as it is published.
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors.
Summary of review protocol.